Multiple Mammograms Not Covered?
Screening mammogram under Bronze plan (free) indicated a problem and MD ordered a 2nd diagnostic exam then an ultrasound. Insurance denied coverage and I need a 6 month f/u mammogram which I am told is not covered. I am still paying off thousands for 2nd mammogram and ultrasound. HELP
Answer
Preventive screening, including mammograms, is covered at not cost under ObamaCare but additional exams may have cost sharing or may not be covered. That being said anything that is essential should be covered in-network under your plans in-network cost sharing amount. If the insurer is flat out denying coverage than you need to coordinate with the doctor and the insurer and appeal the insurers decision if necessary. Every plan is different, but generally exams and diagnostics related to an initial screening should be covered in-network under ObamaCare's ten essential benefits.
Learn more about appealing.
Learn more about ten essential benefits.
Rate and Comment on the Answer
This site uses Akismet to reduce spam. Learn how your comment data is processed.
Answer Rating:
Will appeal denial of diagnostic mammogram and ultrasound but the insurer and hospital should have advised me of this option. How are we women supposed to know to challange these decisions?
Agree 100%, you can essentially appeal anything an insurer or the marketplace says or does. The practice of denying first and then hoping decisions don’t get appealed is certainly not the most efficient system on earth. Hopefully the internet helps to spread information about people’s rights in healthcare, but not ideal that there is a practice out there that requires everyone to be informed on such a specific subject.
Grandfathered plans can charge co-pays and deductibles for mammograms, but plans are supposed to lose that grandfathered status if those payments go up significantly. We need to know where to ask that plan status be reviewed when they do this.
I don’t have an exact answer.
Healthcare.gov says:
Plans or policies may lose their “grandfathered” status if they make certain significant changes that reduce benefits or increase costs to consumers. A health plan must disclose in its plan materials whether it considers itself to be a grandfathered plan and must also advise consumers how to contact the U.S. Department of Labor or the U.S. Department of Health and Human Services with questions.
https://www.healthcare.gov/glossary/grandfathered-health-plan/
You can also likely contact the state insurance department: http://www.naic.org/state_web_map.htm